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2017 ; 22
(3
): 691-711
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What physicians reason about during admission case review
#MMPMID27469243
Juma S
; Goldszmidt M
Adv Health Sci Educ Theory Pract
2017[Aug]; 22
(3
): 691-711
PMID27469243
show ga
Research suggests that physicians perform multiple reasoning tasks beyond
diagnosis during patient review. However, these remain largely theoretical. The
purpose of this study was to explore reasoning tasks in clinical practice during
patient admission review. The authors used a constant comparative approach-an
iterative and inductive process of coding and recoding-to analyze transcripts
from 38 audio-recorded case reviews between junior trainees and their senior
residents or attendings. Using a previous list of reasoning tasks, analysis
focused on what tasks were performed, when they occurred, and how they related to
the other tasks. All 24 tasks were observed in at least one review with a mean of
17.9 (Min = 15, Max = 22) distinct tasks per review. Two new tasks-assess illness
severity and patient decision-making capacity-were identified, thus 26 tasks were
examined. Three overarching tasks were identified-assess priorities, determine
and refine the most likely diagnosis and establish and refine management
plans-that occurred throughout all stages of the case review starting from
patient identification and continuing through to assessment and plan. A fourth
possible overarching task-reflection-was also identified but only observed in
four instances across three cases. The other 22 tasks appeared to be context
dependent serving to support, expand, and refine one or more overarching tasks.
Tasks were non-sequential and the same supporting task could serve more than one
overarching task. The authors conclude that these findings provide insight into
the 'what' and 'when' of physician reasoning during case review that can be used
to support professional development, clinical training and patient care. In
particular, they draw attention to the iterative way in which each task is
addressed during a case review and how this finding may challenge conventional
ways of teaching and assessing clinical communication and reasoning. They also
suggest that further research is needed to explore how physicians decide why a
supporting task is required in a particular context.
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